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USOO7452861 B2

(12) United States Patent (10) Patent No.: US 7.452,861 B2 Kaniga (45) Date of Patent: Nov. 18, 2008

(54) USE OF AN ECHINOCANDIN Chiou et al., “Synergy, Pharmacodynamics, and Time-Sequenced AGENT IN COMBINATION WITH A Ultrastructural Changes of the Interaction between Nikkomycin Z. GLYCOPEPTIDE ANTIBACTERAL AGENT and the Echinocandin FK463 against Aspergillus filmigatus'. Anti microbial Agents and Chemotherapy, vol. 45, No. 12, pp. 3310-3321 (75) Inventor: Koné Kaniga, Hayward, CA (US) (2001). Denning, "Echinocandins:a new class of antifungal'. Journal of Anti (73) Assignee: Theravance, Inc., South San Francisco, microbial Chemotherapy, 49, pp. 889-891 (2002). CA (US) Denning, "Echinocandin antifungal drugs'. The Lancet, vol. 362, pp. (*) Notice: Subject to any disclaimer, the term of this 1142-1151 (2003). patent is extended or adjusted under 35 Eliopoulos et al., “Antimicrobial Combinations'. Antibiotics in U.S.C. 154(b) by 486 days. Laboratory Medicine, 4th Edition, Williams & Wilkins, pp. 330-396 (1996). (21) Appl. No.: 10/895.492 Groll et al., ": pharmacology, safety and therapeutic potential in Superficial and invasive fungal infections'. Expert Opin. (22) Filed: Jul. 21, 2004 Investig. Drugs, 10(8), pp. 1545-1558 (2001). Hossain et al., “New investigational antifungal agents for treating (65) Prior Publication Data invasive fungal infections'. Expert Opin. Invest. Drugs, 9(8), pp. US 2005/OO26819 A1 Feb. 3, 2005 1797-1813 (2000). Lewis et al., “Rationale for Combination Antifungal Therapy'. Related U.S. Application Data Pharmacotherapy, vol. 21, No. 8, pp. 149s-164s (2001). Manavathu et al., “Differential activity of in two-drug com (60) Provisional application No. 60/489,173, filed on Jul. binations with the echinocandin caspofungin against Aspergillus 22, 2003. fumigatus”. J. of Antimicrobial Chemotherapy, 51, pp. 1423-1425 (2003). (51) Int. Cl. Nicolaou et al., “Chemistry, Biology, and Medicine of the A6 IK 38/16 (2006.01) Glycopeptide Antibiotics”. Angew. Chem. Int. Ed., 38, pp. 2096 A6 IK 38/00 (2006.01) 2152 (1999). A63I/33 (2006.01) Shalit et al., “In Vitro Synergy of Caspofungin and AOIN 43/00 (2006.01) against Aspergillus spp. MIC versus Minimal Effective Concentra (52) U.S. Cl...... 514/8: 514/183: 514/9 tion End Points'. Antimicrobial Agents and Chemotherapy, vol. 47. (58) Field of Classification Search ...... None No. 4, pp. 1416-1418 (2003). See application file for complete search history. Sugar, "Overview: Antifungal combination therapy”, Current Opin (56) References Cited ion in Investigational Drugs, 2(10), pp. 1364-1365 (2001). Vanden Bossche, “Echinocandins-an update'. Expert Opin. Ther. U.S. PATENT DOCUMENTS Patents, 12(2), pp. 151-167 (2002). 5,378,804 A 1/1995 Balkovec et al. Lacroix, C., et al., "Echinocandins: a new class of antifungal agents'. 5,925,616 A 7, 1999 Whittemore Medicine et maladies infectieuses, 33(4): 183-191, Apr. 2003. (in 6,107,458 A 8, 2000 Ohki et al. French with English abstract). 6,267,979 B1* 7/2001 Raad et al...... 424/405 Link, H., “Antimicrobial prophylaxis and therapy in neutropenia'. 6,635,618 B2 10/2003 Leadbetter et al. Mycoses 46(Suppl. 2):21-32, Feb. 2003. (in German with English 6,719,991 B2 * 4/2004 Darouiche et al...... 424/422 abstract). 6,743,777 B1 6, 2004 Burkhardt et al. 2003, OO17975 A1 1/2003 Ikeda et al. (Continued) 2004/0242505 A1 12/2004 Kaniga 2005/0026819 A1* 2/2005 Kaniga ...... 5148 Primary Examiner Cecilia J Tsang Assistant Examiner Marcela M Cordero Garcia FOREIGN PATENT DOCUMENTS (74) Attorney, Agent, or Firm Jeffrey A. Hagenah EP O 525.499 A1 2, 1993 EP O 667 353 A1 8, 1995 (57) ABSTRACT WO WOOOf72865 A2 12/2000 OTHER PUBLICATIONS This invention is directed to methods of administering an Ge et al. Vancomycin Derivatives That Inhibit Peptidoglycan echinocandin antifungal agent in combination with a glyco Biosynthesis Without Binding D-Ala-D-Ala. Sciene. Apr. 16, 1999. peptide antibacterial agent having a Substituent comprising at vol. 284, pp. 507-511.* Giglione et al. The situation on antimicrobial agents and chemo least about 8 carbon atoms. The invention is also directed to therapy in 2002: Highlights of the 42nd ICAAC. Sep. 27-30, 2002, methods of using an echinocandin antifungal agent in com San Diego, USA.Expert Opin. Ther. Targets. 2002. vol. 6 No. 6, pp. bination with a specified glycopeptide antibacterial agent to 691-697. treat fungal infections; and to compositions, kits and systems Boger. Vancomycin, Teicoplanin and Ramoplanin. Medicinal comprising an echinocandin antifungal agent and a specified Research Reviews. 2001. vol. 21, No. 5, pp. 356-381.* glycopeptide antibacterial agent. Arikan et al., “New agents for the treatment of systemic fungal infections-current status'. Expert Opin. Emerging Drugs, 7(1), pp. 3-32 (2002). 9 Claims, No Drawings US 7,452,861 B2 Page 2

OTHER PUBLICATIONS tobramycin and piperacillin: Effect on cyclosporine A-associated nephrotoxicity'. Antimicrobial Agents and Chemotherapy, vol. 35 Preobrazhenskaya, M. and Olsufyeva, E., “Patents on glycopeptides No. 11, pp. 2246-2252 (Nov. 1991). of the Vancomycin family and their derivatives as antimicrobials: Jan. Pace, John L., “TD-6424: A novel multifunctional antibiotic'. Abstr 1999-Jun. 2003”. Expert Opin. Ther: Patents, 14(2):141-173, 2004. Intersci ConfAntimicrob Agents Chemother; 42: Abstract No. 614. Taccone F.S., et al., Caspofungin Salvage therapy in a neutropenic Sep. 27-30, 2002. patient with probable invasive aspergillosis: a case report, Supportive Office Action in U.S. Appl. No. 10/854.575, dated Nov. 24, 2006. Care in Cancer. Official Journal of the Multinational Association of Office Action in U.S. Appl. No. 10/854.575, dated Apr. 27, 2007. Supportive Care in Cancer, 11(11):742-744, Nov. 2003. Office Action in U.S. Appl. No. 10/854.575, dated Aug. 6, 2007. Kureishi et al., “Double-blind comparison of teicoplanin versus vancomycin in febrile neutropenic patients receiving concomitant * cited by examiner US 7,452,861 B2 1. 2 USE OF AN ECHNOCANDIN ANTIFUNGAL In yet another of its method aspects, this invention provides AGENT IN COMBINATION WITH A a method for increasing the efficacy of an echinocandin anti GLYCOPEPTIDE ANTIBACTERAL AGENT fungal agent, the method comprising administering the echi nocandin antifungal agent to a subject in combination with a CROSS REFERENCE TO RELATED glycopeptide antibacterial agent having a substituent com APPLICATIONS prising at least about 8 carbon atoms. In one of its composition aspects, this invention provides a This application claims the benefit of U.S. Provisional pharmaceutical composition comprising: Application No. 60/489,173, filed on Jul. 22, 2003; the entire (a) an echinocandin antifungal agent; disclosure of which is incorporated herein by reference in its 10 (b) a glycopeptide antibacterial agent having a substituent entirety. comprising at least about 8 carbon atoms; and (c) a pharmaceutically acceptable carrier. BACKGROUND OF THE INVENTION In another aspect, this invention provides a kit comprising: (a) an echinocandin antifungal agent; and 1. Field of the Invention 15 (b) a glycopeptide antibacterial agent having a substituent This invention relates to the use of an echinocandin anti comprising at least about 8 carbon atoms. fungal agent in combination with a glycopeptide antibacterial In one embodiment, the kit further comprises instructions agent. More specifically, this invention relates to methods of for administering the antifungal and antibacterial agents to a using an echinocandinantifungal agent in combination with a Subject in need of treatment. glycopeptide antibacterial agent to treat fungal infections; In yet another aspect, this invention provides a system for and to compositions, kits and systems comprising an echi treating a fungal infection in a subject, the system compris nocandin antifungal agent and a glycopeptide antibacterial ing: agent. (a) an echinocandin antifungal agent; and 2. State of the Art (b) a glycopeptide antibacterial agent having a substituent Echinocandin antifungal agents, such as caspofungin, 25 comprising at least about 8 carbon atoms. and , are a relatively new class of This invention is also directed to the use of: therapeutic agents useful for treating fungal infections. Gen (a) an echinocandin antifungal agent; and erally, such echinocandin antifungal agents have been found (b) a glycopeptide antibacterial agent having a substituent to have fewer side effects than, for example, polyene antifun comprising at least about 8 carbon atoms; gal agents such as . However, numerous 30 in the manufacture of a medicament for the treatment of a adverse effects have been reported for echinocandin antifun fungal infection. gal agents including headache, fever, liver toxic effects, phle In particular, this invention is directed to the use of an bitis, histamine release, haemolysis and rash. See, for echinocandin antifungal agent in the manufacture of a medi example, Denning, "Echinocandin antifungal drugs. Lancet cament for administration in combination with a glycopep 2003; 362: 1142-51. 35 tide antibacterial agent having a Substituent comprising at Accordingly, a need exists for new methods of administer least about 8 carbon atoms for the treatment of a fungal ing echinocandin antifungal agents that reduce the side infection. effects of Such agents. In particular, a need exists for new Moreover, this invention is directed to the use of a glyco methods and compositions that enhance the efficacy of Such peptide antibacterial agent having a Substituent comprising at antifungal agents thereby permitting Such agents to be admin 40 least about 8 carbon atoms in the manufacture of a medica istered in reduced amounts. ment for administration in combination with an echinocandin antifungal agent for the treatment of a fungal infection. SUMMARY OF THE INVENTION In yet another of its aspects, this invention provides a combination comprising: The present invention provides a novel method of admin 45 (a) an echinocandin antifungal agent; and istering an echinocandin antifungal agent in combination (b) a glycopeptide antibacterial agent having a substituent with a glycopeptide antibacterial agent. Surprisingly, it has comprising at least about 8 carbon atoms. now been discovered that, when a glycopeptide antibacterial agent having a Substituent comprising at least about 8 carbon DETAILED DESCRIPTION OF THE INVENTION atoms is administered in combination with an echinocandin 50 antifungal agent, the efficacy of the echinocandin antifungal The present invention provides a novel method of admin agent is Substantially increased. Accordingly, when used in istering an echinocandin antifungal agent to a Subject in need combination with Such a glycopeptide antibacterial agent, the of treatment. A feature of the present invention is that the amount of echinocandin antifungal agent needed to treat a echinocandin antifungal agent is administered to the Subject fungal infection is reduced. 55 in combination with a glycopeptide antibacterial agent hav Accordingly, in one of its method aspects, this invention ing a Substituent comprising at least about 8 carbon atoms. provides a method for administering an echinocandin anti The antifungal and antibacterial agents may be administered fungal agent to a Subject, the method comprising administer sequentially or simultaneously; and may be in the same or ing to the Subject an echinocandin antifungal agent and a separate formulations. Also provided are compositions, glycopeptide antibacterial agent having a Substituent com 60 including pharmaceutical compositions, kits and systems, prising at least about 8 carbon atoms. comprising an echinocandinantifungal agent and a glycopep In another of its method aspects, this invention provides a tide antibacterial agent as defined herein. method for treating a fungal infection in a subject, the method Before the present invention is described further, it is to be comprising administering to the Subject an antifungal amount understood that the invention is not limited to the particular of an echinocandin antifungal agent and a glycopeptide anti 65 embodiments of the invention described herein, as variations bacterial agent having a substituent comprising at least about of the particular embodiments may be made and still fall 8 carbon atoms. within the scope of the appended claims. It is also to be US 7,452,861 B2 3 4 understood that the terminology employed herein is for the The term “alkoxy' means a monovalent group of the for purpose of describing particular embodiments and is not mula (alkyl)-O , where alkyl is as defined herein. Represen intended to be limiting. Instead, the scope of the present tative alkoxy groups include, by way of example, methoxy, invention will be established by the appended claims. ethoxy, n-propoxy, isopropoxy, n-butoxy, sec-butoxy, isobu In this specification and the appended claims, the singular toxy, tert-butoxy and the like. forms “a,” “an and “the include plural reference unless the The term “thioalkoxy' means a monovalent group of the context clearly dictates otherwise. Unless defined otherwise, formula (alkyl)-S , where alkyl is as defined herein. Repre all technical and Scientific terms used herein have the same sentative thioalkoxy groups include, by way of example, meaning as commonly understood by one of ordinary skill in 10 CH, S CHCH. S. , CHCHCH S (CH) the art to which this invention belongs. CH, S , and the like. Where a range of values is provided, it is understood that The term "halo' means fluoro, chloro, bromo and iodo. each intervening value, to the tenth of the unit of the lower The term "heteroaryl means a monovalent aromatic group limit unless the context clearly dictates otherwise, between having a single ring or two fused rings and containing in the the upper and lower limit of that range, and any other stated or 15 ring at least one heteroatom (typically 1 to 3 heteroatoms) intervening value in that stated range, is encompassed within selected from nitrogen, oxygen or Sulfur. Unless otherwise the invention. The upper and lower limits of these smaller defined, such heteroaryl groups typically contain from 5 to 10 ranges may independently be included in the Smaller ranges, total ring atoms. Representative heteroaryl groups include, by and are also encompassed within the invention, Subject to any way of example, monovalent species of pyrrole, , specifically excluded limit in the stated range. Where the thiazole, oxazole, oxadiazole, furan, thiophene, , stated range includes one or both of the limits, ranges exclud pyrazole, isoxazole, isothiazole, thiadiazole, pyridine, pyra ing either or both of those included limits are also included in Zine, pyridazine, pyrimidine, triazine, indole, benzofuran, the invention. benzothiophene, , benzthiazole, quinoline, 25 Definitions isoquinoline, quinazoline, quinoxaline and the like, where the When describing the compounds, compositions, methods, point of attachment is at any available carbon or nitrogen ring kits, systems and processes of this invention, the following atom. Representative heteroaryls include isoxazolyl, thiadia terms have the following meanings unless otherwise indi Zolyl, oxadiazolyl, imidazolyl pyridyl, pyrrolyl and furyl. cated. 30 The term "heteroarylene' means a divalent heteroaryl The term “alkyl means a monovalent saturated hydrocar group. bon group which may be linear or branched. Unless otherwise The term "saccharide group” means an oxidized, reduced defined. Such alkyl groups typically contain from 1 to 15 or Substituted Saccharide monoradical covalently attached to carbonatoms. Representative alkyl groups include, by way of the glycopeptide or other compound via any atom of the example, methyl, ethyl, n-propyl, isopropyl. n-butyl, sec 35 saccharide moiety, e.g., via the aglycone carbon atom. The butyl, isobutyl, tert-butyl, n-pentyl, n-hexyl, n-heptyl, n-oc term includes amino-containing saccharide groups. Repre sentative saccharide include, by way of illustration, hexoses tyl, n-nonyl, n-decyl and the like. Such as D-glucose, D-mannose, D-xylose, D-galactose, van When a specific number of carbon atoms is intended for a cosamine, 3-desmethyl-Vancosamine, 3-epi-Vancosamine, particular term used herein, the number of carbon atoms is 40 4-epi-Vancosamine, acosamine, actinosamine, daunosamine, shown preceding the term. For example, the term “Cs. 3-epi-daunosamine, ristosamine, D-glucamine, N-methyl-D- alkyl means an alkyl group having from 8 to 12 carbon glucamine, D-glucuronic acid, N-acetyl-D-glucosamine, atOmS. N-acetyl-D-galactosamine, sialyic acid, iduronic acid, L-fu The term “alkylene' means a divalent saturated hydrocar 45 cose, and the like; pentoses Such as D-ribose or D-arabinose; bon group which may be linear or branched. Unless otherwise ketoses such as D-ribulose or D-fructose; disaccharides such defined. Such alkylene groups typically contain from 1 to 10 as 2-O-(C-L-Vancosaminyl)-3-D-glucopyranose, 2-O-(3- carbon atoms. Representative alkylene groups include, by desmethyl-O-L-Vancosaminyl)-3-D-glucopyranose. Sucrose, way of example, methylene, ethane-1,2-diyl (“ethylene'), lactose, or maltose; derivatives such as acetals, amines, acy propane-1,2-diyl, propane-1,3-diyl, butane-1,4-diyl, pen 50 lated, Sulfated and phosphorylated Sugars; oligosaccharides tane-1,5-diyl and the like. having from 2 to 10 saccharide units. For the purposes of this The term “alkenyl' means a monovalent unsaturated definition, the Saccharide can be either in its open or in cyclic hydrocarbon group which may be linear or branched and form (i.e., the pyranose form for hexoses). which has at least one, and typically 1, 2 or 3, carbon-carbon 55 The term "amino-containing saccharide group” means a double bonds. Unless otherwise defined, such alkenyl groups saccharide group having an amino Substituent. Representa typically contain from 2 to 15 carbon atoms. Representative tive amino-containing saccharides include L-Vancosamine, alkenyl groups include, by way of example, ethenyl, n-pro 3-desmethyl-Vancosamine, 3-epi-Vancosamine, 4-epi-van penyl, isopropenyl. n-but-2-enyl, n-hex-3-enyl and the like. cosamine, acosamine, actinosamine, daunosamine, 3-epi The term “alkynyl means a monovalent unsaturated 60 daunosamine, ristosamine, N-methyl-D-glucamine and the hydrocarbon group which may be linear or branched and like. which has at least one, and typically 1, 2 or 3, carbon-carbon A “substituent comprising at least 8 carbon atoms” means triple bonds. Unless otherwise defined, such alkynyl groups any Substituent having at least 8 carbonatoms which Substitu typically contain from 2 to 15 carbon atoms. Representative 65 ent may also contain other atoms such as oxygen, nitrogen, alkynyl groups include, by way of example, ethynyl. n-pro sulfur or halo; or combinations thereof. When attached to a pynyl. n-but-2-ynyl, n-hex-3-ynyl and the like. glycopeptide antibacterial agent, such a Substituent is US 7,452,861 B2 5 6 attached to either (1) the amino acids (AA 1-7) that form the disease state being treated, the severity of the affliction and core of the glycopeptide antibacterial agent, or (2) a mono- or the manner of administration, and may be determined rou polysaccharide group of the glycopeptide antibacterial agent. tinely by one of ordinary skill in the art. When determining the number of carbon atoms in the sub The term “antifungal amount’ means an amount Sufficient stituent, this term does not include any carbon atoms of the 5 to treat a fungal infection or medical condition. amino acids (AA 1-7) that form the core of the glycopeptide, The term “antibacterial amount’ means an amount suffi or any carbonatoms that form the rings of a mono- or polysac cient to treat a bacterial infection or medical condition. charide group attached to the glycopeptide core. The Glycopeptide Antibacterial Agent “Pharmaceutically acceptable salt” means those salts 10 The glycopeptide antibacterial agent employed in this which retain the biological effectiveness and properties of the parent compounds and which are not biologically or other invention is any glycopeptide antibacterial agent having a wise harmful at the dosage administered. Active agents Substituent comprising at least about 8 carbon atoms. Glyco employed in methods of the subject invention are capable of peptide antibacterial agents are a well known class of anti 15 bacterial agents. See, for example, Nicolaou et al., Angew forming both acid and base salts by virtue of the presence of Chem. Int. Ed. (1999) 38:2096-2152; and Rao et al., Glyco amino and carboxy groups respectively. peptides Classification, Occurrence, and Discovery. In Gly Pharmaceutically acceptable base addition salts may be copeptide Antibiotics; Ramakrishnan Nagarajan Ed., Marcel prepared from inorganic and organic bases. Salts derived Dekker, Inc.: New York, N.Y., 1994; Volume 63, pp 1-27. from inorganic bases include, but are not limited to, the Glycopeptide antibacterial agents typically have a multi Sodium, potassium, lithium, ammonium, calcium, and mag ring peptide core comprising seven amino acids (i.e., AA-1 to nesium salts. Salts derived from organic bases include, but are not limited to, salts of primary, secondary and tertiary amines, AA-7) and at least 5 aromatic rings (i.e., rings A through E). Substituted amines including naturally-occurring Substituted The peptide core is optionally substituted with one or more 25 saccharide groups. Type I structures contain aliphatic rings in amines, and cyclic amines, including isopropylamine, trim AA-1 and AA-3. Type II, type III and type IV structures ethyl amine, diethylamine, triethylamine, tripropylamine, include aromatic side chains within these amino acids. Fur ethanolamine, 2-dimethylaminoethanol, tromethamine, thermore, type III and IV structures contain an extra F-O-G lysine, arginine, histidine, caffeine, procaine, hydrabamine, ring system. In addition, type IV compounds have a long choline, betaine, ethylenediamine, glucosamine, N-alkylglu 30 fatty-acid chain attached to the Sugar moiety. Type V com camines, theobromine, purines, piperazine, piperidine, and pounds contain a tryptophan moiety linked to the central N-ethylpiperidine. It should also be understood that other amino acid. carboxylic acid derivatives would be useful in the practice of this invention, for example carboxylic acid amides, including Examples of glycopeptide antibacterial agents include carboxamides, lower alkyl carboxamides, di(lower alkyl) car 35 those identified as A477, A35512, A40926, A41030, A42867, A47934, A80407, A82846, A83850, A84575, AB-65, acta boxamides, and the like. planin, actinoidin, ardacin, avoparcin, azureomycin, balhi Pharmaceutically acceptable acid addition salts may be mycin, chloroorientiein, chloropolysporin, dalbavancin, prepared frominorganic and organic acids. Salts derived from decaplanin, N-demethylvancomycin, eremomycin, galacar inorganic acids include hydrochloric acid, hydrobromic acid, 40 Sulfuric acid, nitric acid, phosphoric acid and the like. Salts din, helvecardin, izupeptin, kibdelin, LL-AM374, man derived from organic acids include acetic acid, propionic nopeptin, MM45289, MM47756, MM47761, MM49721, acid, glycolic acid, pyruvic acid, oxalic acid, malic acid, MM47766, MM55260, MM55266, MM55270, MM56597, malonic acid. Succinic acid, maleic acid, fumaric acid, tartaric MM56598, OA-7653, orenticin, oritivancin, parvodicin, ris 45 tocetin, ristomycin, Synmonicin, teicoplanin, telavancin, acid, citric acid, benzoic acid, cinnamic acid, mandelic acid, UK-68597, UK-69542. UK-72051, Vancomycin, and the methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic like; and semi-synthetic derivatives thereof. acid, and the like. Additional examples of glycopeptide antibacterial agents The term “treating or “treatment” as used herein means are disclosed in U.S. Pat. Nos. 4,639,433; 4,643,987; 4,497, the treating or treatment of a disease or medical condition 50 802; 4,698,327: 5,591,714; 5,840,684; and 5,843,889; in EP (such as a fungal infection) in a subject or patient, such as a 0802199; EP 0 801 075; EP 0667 353; WO 97/28812; WO mammal (particularly a human) that includes: 97/38702; WO 98/52589; WO 98/52592; and in J. Amer: (a) preventing the disease or medical condition from occur ring, i.e., prophylactic treatment of a patient; Chem. Soc., 1996, 118, 13107-13108, J. Amer: Chem. Soc., (b) ameliorating the disease or medical condition, i.e., 55 1997,119, 12041-12047; and J. Amer: Chem. Soc., 1994, 116, eliminating or causing regression of the disease or medi 4573-4590. cal condition in a patient; Another group of glycopeptide antibacterial agents are (c) suppressing the disease or medical condition, i.e., slow those in which the N-terminal amino acid of a naturally ing or arresting the development of the disease or medi occurring glycopeptide antibacterial agent has been removed cal condition in a patient; or 60 (i.e., a hexapeptide). Methods for preparing Such hexapep (d) alleviating the symptoms of the disease or medical tides are disclosed in U.S. Pat. No. 5,952,310; and P. M. condition in a patient. Booth et al., J. Chem. Soc., Chem. Commun. (1987) 1964 The term “therapeutically effective amount’ means an 1965. amount sufficient to effect treatment when administered to a 65 The term "semi-synthetic glycopeptide antibacterial subject or patient in need of treatment. The therapeutically agent’ means a glycopeptide antibacterial agent that is pro effective amount will vary depending on the Subject and duced by modifying a naturally-occurring glycopeptide anti US 7,452,861 B2 7 bacterial agent, e.g., through modification of the outer sphere wherein of the parent compound; or through degradation and reassem bly of the cyclopeptide core with incorporation, for example, X' and X’ are independently hydrogen or chloro; of new amino acid components. The term "synthetic glyco peptide antibacterial agent’ means any non-naturally occur R' selected from the group consisting of: ring glycopeptide antibacterial agent, whether or not it is a modified naturally-occurring compound, i.e., a semi-syn (a) R': thetic compound. When defining the glycopeptide antibacte (b) C(O) R: rial agents of this invention, the terms “type I.” “type II,” “type 10 III,” “type IV,” “type V” “semi-synthetic,” and “outer-sphere' (c) R. W.'; are used as defined in the art (for example, as used the above (d) C(O) R' W; and cited Nicolaou et al., review). (e) R Y R?: The particular glycopeptide antibacterial agents used in this invention are those having a Substituent comprising at 15 where least about 8 carbon atoms. In this regard, the glycopeptide R" and Rare independently Csa alkyl, Csa alkenyl or antibacterial agent may be a naturally-occurring glycopeptide Calkynyl: antibacterial agent or a synthetic glycopeptide antibacterial R and Rare independently Cls alkylene; agent (including a semi-synthetic glycopeptide antibacterial agent). R is Cls alkylene; Typically, the Substituent comprising at least about 8 car R is C1-12 alkyl, C-12 alkenyl or C-12 alkynyl: bon atoms will contain from about 8 to about 24 carbon W' and W are independently phenyl optionally substi atoms, including from about 8 to about 20 carbonatoms. Such tuted with 1 to 3 substituents independently selected from the as from about 8 to about 14 carbonatoms; and from 0 to about 25 group consisting of C- alkyl, C- alkoxy, halo, -(phenyl). 5 heteroatoms selected from oxygen, nitrogen, Sulfur or halo. —CH-(phenyl). —O-(phenyl), and —O—CH-(phenyl); The carbon atoms of such substituents may be linear or wherein each -(phenyl) group is optionally Substituted with 1 branched or may be joined to formaliphatic or aromatic rings, or 2 substituents independently selected from the group con Such as phenyl rings. The optional heteroatoms may interrupt 30 sisting of C alkyl, Calkoxy and halo; the carbon chain, i.e., to form ethers, thioethers or amines, or Y is O, S or NH; may be substituents attached to the carbon chain, such as a chloro substituent. and provided that R' comprises at least 8 carbonatoms; In certain embodiments, the glycopeptide antibacterial one of R and Rhydroxy and the other is hydrogen; agent is a compound of formula I: R" and Rare independently hydrogen or methyl;

US 7,452,861 B2 9 10 R is hydrogen or a group of formula (f): In yet another specific embodiment of interest, the glyco peptide antibacterial agent is a teicoplanin. As used herein, the term teicoplanin include teicoplanin A-1 to 5, i.e., includes one or more of teicoplanin A-1; teicoplanin A-2; teicoplanin A-3; teicoplanin A-4; and teicoplanin A-5.

(f) In a particular embodiment, the glycopeptide antibacterial agent is selected from telavancin, oritavancin, dalbavancin and teicoplanin; or a pharmaceutically acceptable salt 10 thereof. Also of interest are derivatives of Such compounds, e.g., compounds in which modifications to one or more of the above moieties or groups have been made and which deriva 15 tives retain antibacterial activity. Such glycopeptide antibacterial agents are commercially available or can be conventionally prepared by techniques R’ is hydrogen or a group of formula (g): known to one of skill in the art. For example, representative patents describing various glycopeptide compounds and derivatives thereof, as well as the synthesis or preparation thereof, include U.S. Pat. Nos. 4,497,802; 4,639,433; 4,643, (g) 987; 4,698,327: 5,591,714:5,750,509; 5,916,873; 5,919,756; opo 5,840,684; 5,840,684; 5,843,889; 5,977,062; and 6,444,786; 25 as well as published U.S. Application Publication Nos. 2002/ 0022590 A1: 2003/008812 A1: 2003/0045457 A1; and 2003/ OH OO69391 A1. The Echinocandin Antifungal Agent 30 The echinocandin antifungal agents employed in this n is an integer from 1 to 6; invention area well known class of antifungal agents. See, for or a pharmaceutically-acceptable salt thereof or stereoiso example, Denning, "Echinocandin antifungal drugs. Lancet mer thereof. 2003; 362: 1142-51. Such echinocandin antifungal agents In a specific embodiment of interest, the glycopeptide anti include lipopeptide agents which are cyclopeptides, e.g., bacterial agent is a compound of formula I, where: X' and X 35 cyclic hexapeptides, as well as non-cyclopeptide functional are both chloro; R' is —CHCH NH-(CH2)6CH; R is analogues thereof, e.g., corynecandin, etc. hydroxy; R is hydrogen; R is methyl; R is hydrogen; R is The echinocandinantifungal agent employed in this inven hydrogen; and R7 is —CH2 NH-CH P(O)(OH). This tion may be a naturally-occurring echinocandin antifungal compound is known in the art as telavancin. 40 agent or a synthetic or semi-synthetic derivative thereof. In another specific embodiment of interest, the glycopep tide antibacterial agent is a compound of formula I, where: X' Representative naturally-occurring echinocandin antifun and X’ are both chloro; R is a group of the formula: gal agents of interest include, but are not limited to: echi nocandin B (ECB), echinocandin C, aculeacin Ay, mulun docandin, sporiofungin A, pneumocandin A WF11899A, 45 and pneumocandin Bo. Synthetic and semi-synthetic echinocandin antifungal -ci-( )-( )—c agents of interest include analogues of the above naturally occurring echinocandin compounds, e.g., analogues of echi R’ is hydrogen; R is hydroxy: R is methyl; R is hydrogen; 50 nocandin B. Such as cillofungin and anidulafungin; analogues R is a group of formula (f); and R is hydrogen. This com of WF11899A, such as micafungin; and analogues of pneu pound is known in the art as oritavancin. mocandin Bo. Such as caspofungin. In another specific embodiment of interest, the glycopep The echinocandin antifungal agents employed in this tide antibacterial agent is a compound of formula I, where: X' 55 invention are commercially available or can be prepared by and X’ are both chloro; R is a group of the formula: techniques known to those skilled in the art. For example, representative patents and patent applications describing various echinocandin antifungal agents and derivatives thereof, as well as the synthesis and preparation of Such —cil ( )-( )—c 60 agents, include U.S. Pat. Nos. 5,378,804: 5,514,650; 5,541, 160; 5,782,746; 5,952,300; 6,136,783; 6,107,458; 6.232,290: US 2003/0017975; WO 98/52967; WO 99/20651; WO R’ is hydroxy: R is H; R is methyl; R is hydrogen; R is 99/29716; WO99/.43337; WO99/55727; WO 00/11023; WO hydrogen; and R is hydrogen. 65 00/34315; WO 00/51564: WO00/51567; WO 00/52036: WO In yet another specific embodiment of interest, the glyco 00/52037; WO 00/63239; WO00/75177; WO 00/75178; WO peptide antibacterial agent is dalbavancin. 01/02002; and WO 01/07468. US 7,452,861 B2 11 12 In one embodiment, the echinocandinantifungal agent is a together are —(CH) , —(CH) , —(CH2)2O(CH2) - compound of formula II: or —(CH), NH-(CH) ; and where each RandR are independently hydrogen or C. alkyl, or a pharmaceutically acceptable salt or Stereoisomer II thereof. In one embodiment of formula II, R' is C(O)R3, where R is as defined herein. In a specific embodiment of this aspect of the invention, R is selected from the group consisting of Calkyland C-20 alkenyl. Examples of particular values for 10 R3 are —(CH), CH, —(CH) -CH(CH)—CH2—, —CH, -(CH2)o CH(CH,)—CH, CH, -(CH), CH=CH-CH CH=CH-(CH) CH and —CH=C(CH)—(CH) CH=C(CH). In another embodiment of formula II, R' is —C(O)— 15 W. R", where W and R" areas defined herein. In a specific embodiment of this aspect of the invention, W is unsubsti tuted 1,4-phenylene; and R' is selected from the group con sisting of C, alkoxy and -O-(CH2) O-C, alkyl, where p is 2 to 12. Particular values of R' for this and other embodiments are —O(CH2)CH, —O(CH2)CH, —O(CH2)CH, —O(CH), CH, -O(CH2)CH, -O- (CH), O CHs and -O-(CH2). O-(CH2), CHs. Examples of particular values for W. R" are: 25

wherein: O-(CH)-CH and R" is selected from the group consisting of: (a) hydrogen; 30 (b) C(O)Rs: (C)= C(O). W. R'; O-(CH)-O-(CH)-CH. (d) C(O). W. W. R"; (e) C(O). W. W. W. R: (f) C(O). W. C=C W R: 35 In still another embodiment of formula II, R' is —C(O)— (g) - C(O) W. W. C=C W. R: W. W. R", where each W and R' are as defined herein. where In a specific embodiment of this aspect of the invention, each R is C1-2 alkyl, C2-20 alkenyl or C2-20 alkynyl: W is unsubstituted 1,4-phenylene; and R' is selected from R" is selected from the group consisting of hydrogen, C-12 the group consisting of C-12alkoxy and -O-(CH), O— alkyl, C2-12 alkenyl, C2-12 alkynyl, C-12 alkoxy, C-12 thio 40 C. alkyl, where p is 2 to 12. alkoxy, halo and—O-(CH2) O-C-2 alkyl, wherep is 2 An example of a particular value for W W R is: to 12: each W and W is independently 1,4-phenylene or C. heteroarylene containing 1 to 3 heteroatoms selected from the group consisting of oxygen, nitrogen or Sulfur, wherein the 45 phenylene or heteroarylene group is optionally substituted with 1 to 3 substituents independently selected from the group consisting of Coalkyl, C2-alkenyl, C2-alkynyl, C alkoxy, C. thioalkoxy and halo: In yet another embodiment of formula II, R' is C(O)— R''", R'', R', and R'' are independently selected from 50 W. W. W. R", where each W, W and R are as hydrogen or hydroxy; or R'" is NH(CH2)NH2 or NH defined herein. In a specific embodiment of this aspect of the (2-aminocyclohex-1-yl); invention, each W is unsubstituted 1,4-phenylene; W is R" is hydrogen, hydroxy, amino or methyl; unsubstituted 1,4-phenylene or unsubstituted heteroarylene selected from the group consisting of 1,3,4-thiadiazol-2.5- R" is hydrogen, methyl, —CHCN, —CHCONH or 55 —CHCH-NH; diyl, isoxazol-3,5-diyl. 1,3,4-oxadiazol-2,5-diyl, 1.2.4-Oxa R'' is hydrogen or hydroxy: diazol-3,5-diyland imidazol-2,4-diyl; and R' is selected from R" is hydroxy, OP(O)(OH), —OP(O)(OH)(OCH), the group consisting of C-12alkoxy and -O-(CH), O— – OP(OH)(OCH) or OSOH: C. alkyl, where p is 2 to 12. R' is hydrogen, hydroxy, OSOH, -SOH or -CH2 60 Examples of particular values for – W. W. W. R' piperidin-1-yl; a. R'' is hydrogen or methyl; and R" is hydrogen, hydroxy, benzyloxy, NR'R' or —O— (CH2)2·NR'R', where R is hydrogen, C. alkyl, Csa alk enyl, -(CH2)2OH, -(CH2)NR'R' or -CO(CH), 65 NH2; where R is hydrogen, C. alkyl, C. alkenyl, —(CH), OH or -(CH2)NR'R' or R and R taken US 7,452,861 B2 13 14 In a specific embodiment of interest, the echinocandin -continued antifungal agent employed in this invention is a compound of - formula II, where R' is a group of the formula: --()-C-K)- O-(CH2)4CH and 5 N-N --( )- S 3-()-o-c-o-ch. 10 In a specific embodiment of formula II, R' is selected from the group consisting of R'', R'', R'', and R'' are OH: R is H; R' hydrogen; (CH), NH.; R is OH: R is OH: Ris-H; R7 is —C(O)—(CH) CH: —CH; and R' is NH-(CH2). NH2. This compound is 15 known as caspofungin. —C(O)—(CH) -CH(CH)—CH2——CH: In another specific embodiment of interest, the echinocan —C(O)–(CH-)-CH=CH-CH-CH=CH din antifungal agent is a compound of formula II, where R' —(CH2), CH, is a group of the formula:

O

O ( )—K)-()--inch. O-(CH2)(CH3, 25 R'', R'', R'', and R'' are OH: R' and Rare CH: O R'' and Rare -OH: Ris-H; R7 is CH, and R' is —OH. This compound is known as anidulafungin. 30 In another specific embodiment of interest, the echinocan din antifungal agent is a compound of formula II, where R' ( ) ( ) O-(CH2)4-CH, is a group of the formula: O 35 O N-O O- (CH2)4CH3, - I () { 2-()-o-clich. O N-O W 40

R'', R'', R'', and R'' are OH: R is CH; R is CH, C(O) NH; R'' and R' are –OH: R is and - SOH: R'' is —CH; and R' is OH. This compound is known as micafungin. O N-N In one embodiment, the echinocandin antifungal agent is 45 selected from the group consisting of caspofungin, anidu ( ) S 3-()-o-c-o-ch. lafungin and micafungin. In a particular embodiment, the echinocandin agent is caspofungin. In one embodiment, the glycopeptide antibacterial agent is telavancin and the echi Particular values of R' can be selected from the group nocandin antifungal agent is caspofungin. consisting of 50 Methods The present invention provides methods of administering an echinocandin antifungal agent to a Subject in need of treatment. A feature of the present methods is that the echi s 55 nocandin antifungal agent is administered to the Subject in O combination with a glycopeptide antibacterial agent having a O Substituent comprising at least about 8 carbon atoms. By “in combination with is meant that an amount of an ( ) ( ) ( ) O-(CH2)4CH echinocandin antifungal agent is administered to the Subject 60 together with an amount of a glycopeptide antibacterial agent. and In certain embodiments, the echinocandin antifungal agent

and glycopeptide antibacterial agent are administered O N-O sequentially, e.g., where the echinocandin antifungal agent is administered before or after the glycopeptide antibacterial 65 agent. In other embodiments, the echinocandin antifungal agent and glycopeptide antibacterial agent are administered simultaneously, e.g., where the echinocandin antifungal US 7,452,861 B2 15 16 agent and glycopeptide antibacterial agent are administered Pharmaceutical Compositions at the same time as two separate formulations or are combined The echinocandin antifungal agent and the glycopeptide into a single composition that is administered to the Subject. antibacterial agent employed in this invention are typically Regardless of whether the echinocandin antifungal agent and formulated as a pharmaceutical composition Suitable for glycopeptide antibacterial agent are administered sequen 5 administration to a Subject in need of treatment. In this regard, tially or simultaneously, the agents are considered to be the echinocandin antifungal agent and the glycopeptide anti administered together or in combination for purposes of the bacterial agent may beformulated as separate pharmaceutical present invention if both agents are present in the patient at the compositions for administration simultaneously or sequen same time. tially to a subject in need of treatment. Alternatively, such Routes of administration of the two agents and the amount 10 agents may be combined in a single pharmaceutical compo of each agent employed will depend on various factors. Such sition, i.e., one composition that includes both active agents. as the particular agents being used, the condition being Generally, when formulated and administered as separate treated and so forth. Generally, the amount of the echinocan pharmaceutical compositions, the echinocandin antifungal din antifungal agent that is administered to the Subject is a agent and the glycopeptide antibacterial agent will be formu therapeutically effective amount to treat the subject for the 15 lated using conventional pharmaceutical compositions well condition afflicting the Subject, e.g., for the fungal infection known and previous described in the art for Such agents. afflicting the subject. In many embodiments, this effective For example, pharmaceutical compositions suitable for amount is one that is less than the amount which is effective echinocandin antifungal agents are described in U.S. Pat. when the echinocandin antifungal agent is not administered Nos. 5,378,804; 5,952,300; and 6,136,783; and WOOO/ in combination with a glycopeptide antibacterial agent (i.e., 51564: WO00/51567; WO99/.43337; and WO98/52967. Suit in a control administration). For example, when administered able caspofungin formulations include, for example, Canci according to this invention, the amount of echinocandin anti das.(R). fungal agent can typically be reduced by at least about 10% by Additionally, pharmaceutical compositions suitable for weight per dose; in other cases, by at least about 20% by glycopeptide antibacterial agents are described in U.S. Pat. weight per dose; and in still other cases, by at least about 50% 25 Nos. 5,977,062 and 6,635,618: EP 0 667353; EP 0525.499; by weight per dose. In certain representative embodiments, and WOO1/82971. such as when administered by IV infusion, the amount of When the echinocandinantifungal agent and the glycopep echinocandin antifungal agent that is administered to the tide antibacterial agent are formulated together in a single Subject ranges from about 25 mg per day to about 100 mg per pharmaceutical composition, Such compositions are novel. day, such as from about 50 mg per day to about 70 mg per day. 30 Accordingly, in one embodiment, this invention is directed to The amount of glycopeptide antibacterial agent that is a pharmaceutical composition comprising an echinocandin administered to the subject is one that typically increases the antifungal agent; a glycopeptide antibacterial agent having a efficacy of the echinocandin antifungal agent, where efficacy Substituent comprising at least about 8 carbon atoms; and a is considered to be increased if the amount of the echinocan pharmaceutically acceptable carrier, excipient or vehicle. dinantifungal agent required to be effective is decreased by at 35 By way of further illustration, the echinocandin antifungal least about 10% by weight per dose. In certain embodiments, agent and/or the glycopeptide antibacterial agent can be the amount of glycopeptide agent administered to the Subject admixed with conventional pharmaceutical carriers and is one that results in a synergistic increase in the efficacy of excipients (i.e., vehicles) and used in the form of aqueous the echinocandin antifungal agent. By Synergistic increase is Solutions, tablets, capsules, elixirs, Suspensions, syrups, meant that the amount of glycopeptide antibacterial agent 40 wafers, and the like. Such pharmaceutical compositions gen administered to the subject causes the efficacy of the co erally contain, in certain embodiments, from about 0.1 to administered echinocandin antifungal agent to increase Syn about 90% by weight of the active compound, and more ergistically. Synergy can be demonstrated in vitro using, for generally from about 1 to about 30% by weight of the active example, the checkerboard MIC assay, as described in compound. The pharmaceutical compositions may contain Eliopoulos, E.G. and R. Moellering, Jr. “Antimicrobial Com 45 common carriers and excipients. Such as corn starch or gela binations' in Antibiotics in Laboratory Medicine, edited by V. tin, lactose, dextrose. Sucrose, microcrystalline cellulose, Lorian, 4" Ed., Williams & Wilkins, Baltimore, Md., pp. kaolin, mannitol, dicalcium phosphate, Sodium chloride, and 330-396 (1996); Shalit et al., Antimicrobial Agents and Che alginic acid. Disintegrators commonly used in the formula motherapy 47(4): 1416-1418 (2003); or Afeltra et al., Antimi tions of this invention include croscarmellose, microcrystal crobial Agents and Chemotherapy 46(10):3323-3326 (2002); 50 line cellulose, corn starch, sodium starch glycolate and alg and as illustrated in the Experimental Section herein. In many inic acid. embodiments, the amount of glycopeptide antibacterial agent A liquid composition will generally consistofa Suspension that is administered is sufficient to result in a Functional or solution of the compound or pharmaceutically acceptable Inhibitory Concentration Index (FICI) of s().7, including salt in a Suitable liquid carrier(s), for example, ethanol, glyc s0.6, Such as s0.5, as determined using the MIC assay. 55 erine, Sorbitol, non-aqueous solvent such as polyethylene In certain embodiments, for example, when administered glycol, oils or water, with a suspending agent, preservative, by IV infusion, the amount of glycopeptide antibacterial Surfactant, wetting agent, flavoring or coloring agent. agent that is administered to the Subject in any given dose Alternatively, a liquid formulation can be prepared from a ranges from about 0.1 mg/kg to about 50 mg/kg, such as from reconstitutable powder. For example, a powder containing about 0.25 mg/kg to about 25 mg/kg, including from about 60 active compound, Suspending agent, Sucrose and a Sweetener 0.5 mg/kg to about 10 mg/kg. can be reconstituted with water to form a suspension; and a In practicing the methods of this invention, the combina syrup can be prepared from a powder containing active ingre tion of an echinocandin antifungal agent and a glycopeptide dient, Sucrose and a Sweetener. antibacterial agent can be administered in a single daily dose A composition in the form of a tablet can be prepared using or in multiple doses per day. The treatment regimen may 65 any suitable pharmaceutical carrier(s) routinely used for pre require administration over extended periods of time, for paring Solid compositions. Examples of such carriers include example, for several days or for from one to six weeks. magnesium Stearate, starch, lactose. Sucrose, microcrystal US 7,452,861 B2 17 18 line cellulose and binders, for example, polyvinylpyrroli In certain embodiments, the pharmaceutical composition done. The tablet can also be provided with a color film coat containing the glycopeptide antibacterial agent will further ing, or color included as part of the carrier(s). In addition, comprise a cyclodextrin compound. By way of illustration, active compound can be formulated in a controlled release the glycopeptide antibacterial agent, for example, in the form dosage form as a tablet comprising a hydrophilic or hydro a pharmaceutically acceptable salt, can be admixed with an phobic matrix. aqueous cyclodextrin solution to form a pharmaceutical com A composition in the form of a capsule can be prepared position. Such pharmaceutical compositions will typically using routine encapsulation procedures, for example, by contain from about 1 to about 40 weight per ent of the cyclo incorporation of active compound and excipients into a hard dextrin and an effective amount of the glycopeptide antibac gelatin capsule. Alternatively, a semi-solid matrix of active 10 terial agent. In certain embodiments, the cyclodextrin compound and high molecular weight polyethylene glycol employed in the pharmaceutical compositions of this inven can be prepared and filled into a hard gelatin capsule; or a tion is hydroxypropyl-3-cyclodextrin or sulfobutyl ether Solution of active compound in polyethylene glycol or a sus B-cyclodextrin. In certain embodiments, the cyclodextrin is pension in edible oil, for example, liquid paraffin or fraction hydroxypropyl-3-cyclodextrin. In certain embodiments, the ated coconut oil can be prepared and filled into a soft gelatin 15 cyclodextrin will comprise about 1 to 40 weight percent; such capsule. as about 2 to 30 weight percent; including about 5 to 15 Tablet binders that can be included are acacia, methylcel weight percent, of the formulation. In an embodiment, the lulose, Sodium carboxymethylcellulose, poly-vinylpyrroli aqueous cyclodextrin solution further comprises dextrose, done (PoVidone), hydroxypropyl methylcellulose. Sucrose, e.g., about 5% dextrose. starch and ethylcellulose. Lubricants that can be used include Optionally, the pharmaceutical composition may contain magnesium Stearate or other metallic Stearates, Stearic acid, other pharmaceutically acceptable components. Such a buff silicone fluid, talc, waxes, oils and colloidal silica. ers, Surfactants, antioxidants, viscosity modifying agents, Flavoring agents such as peppermint, oil of wintergreen, preservatives and the like. Each of these components is well cherry flavoring or the like can also be used. Additionally, it known in the art. See, for example, U.S. Pat. No. 5,985.310. may be desirable to add a coloring agent to make the dosage 25 Other components suitable for use in the formulations of form more attractive in appearance or to help identify the the present invention can be found in Remington. The Science product. and Practice of Pharmacy, 20th Edition, Lippinoft Williams The compounds of the invention and their pharmaceuti & White, Baltimore, Md. (2000). cally acceptable salts that are active when given parenterally can be formulated for intramuscular, intrathecal, or intrave 30 Kits and Systems nous administration. This invention also provides kits and systems for use in A typical composition for intramuscular or intrathecal practicing the methods described herein. For example, kits administration will be of a suspension or solution of active and systems for practicing the Such methods may include one ingredient in an oil, for example, arachis oil or sesame oil. A or more pharmaceutical compositions, which include one or typical composition for intravenous or intrathecal adminis 35 both of the echinocandin antifungal agent and the glycopep tration will be a sterile isotonic aqueous Solution containing, tide antibacterial agent. For example, in certain embodi for example, active ingredient and dextrose or sodium chlo ments, the kits may include a single pharmaceutical compo ride, or a mixture of dextrose and sodium chloride. Other sition, present as one or more unit dosages, where the examples are lactated Ringers injection, lactated Ringer's composition comprises both the echinocandin antifungal plus dextrose injection, Normosol-M and dextrose, Isolyte E, 40 agent and the glycopeptide antibacterial agent. In yet other acylated Ringer's injection, and the like. Optionally, a co embodiments, the kits may include two or more separate Solvent, for example, polyethylene glycol, a chelating agent, pharmaceutical compositions, each containing either a echi for example, ethylenediamine tetraacetic acid, and an anti nocandin antifungal agent or a glycopeptide antibacterial oxidant, for example, sodium metabisulphite may be agent. included in the formulation. Alternatively, the solution can be 45 In addition to the above components, the kits may further freeze dried and then reconstituted with a suitable solventjust include instructions for practicing the methods of this inven prior to administration. tion. These instructions may be present in the kits in a variety The compounds of the invention and their pharmaceuti of forms, one or more of which may be present in the kit. One cally acceptable salts which are active on rectal administra form in which these instructions may be present is as printed tion can beformulated as Suppositories. A typical Suppository 50 information on a suitable medium or Substrate, e.g., a piece or formulation will generally consist of active ingredient with a pieces of paper on which the information is printed, in the binding and/or lubricating agent such as a gelatin or cocoa packaging of the kit, in a package insert, etc. Yet another butter or other low melting vegetable or synthetic wax or fat. means would be a computer readable medium, e.g., diskette, The compounds of this invention and their pharmaceuti CD, etc., on which the information has been recorded. Yet cally acceptable salts which are active on topical administra 55 another means that may be present is a website address which tion can be formulated as transdermal compositions or trans may be used via the internet to access the information at a dermal delivery devices (“patches'). Such compositions removed site. Any convenient means for providing instruc include, for example, a backing, active compound reservoir, a tions may be present in the kits. control membrane, liner and contact adhesive. Such transder The term "system” as used herein means a collection of an mal patches may be used to provide continuous or discon 60 echinocandin antifungal agent and a glycopeptide antibacte tinuous infusion of the compounds of the present invention in rial agent, present in a single or disparate composition, that controlled amounts. The construction and use of transdermal are brought together for the purpose of practicing the methods patches for the delivery of pharmaceutical agents is well of this invention. For example, separately obtained echi known in the art. See, for example, U.S. Pat. No. 5,023,252, nocandin antifungal agent and glycopeptide antibacterial issued Jun. 11, 1991. Such patches may be constructed for 65 agent dosage forms brought together and co-administered to continuous, pulsatile, or on demand delivery of pharmaceu a Subject in need of treatment, according to the present inven tical agents. tion, are a system according to the present invention. US 7,452,861 B2 19 20 Utility The utility of present invention is further illustrated by the The methods, compositions, kits and systems of this inven following representative Examples. tion are useful for treating a Subject having a fungal infection or medical condition which is caused by a pathogenic organ EXAMPLES ism, e.g., a fungus, that is inhibited by or treatable with an echinocandinantifungal agent. In this regard, the Subject may The following examples are offered to illustrate this inven already have a fungal infection or the combination of an tion and are not to be construed in any way as limiting the echinocandin antifungal agent and a glycopeptide antibacte scope of this invention. In the examples below, the following rial agent may be used in prophylactic therapy and empirical abbreviations have the following meanings unless otherwise 10 indicated. All other abbreviations have their generally therapy where treatment is initiated prior to the identification accepted meaning. of the causative pathogen. A variety of subjects or patients or hosts are treatable using the methods, compositions, kits and systems of the present CFU mL colony-forming units/milliliter invention. Generally such subjects are “mammals' or “mam 15 DMSO Dimethylsulfoxide malian, where these terms are used broadly to describe FIC fractional inhibitory concentration organisms which are within the class mammalia, including FICI fractional inhibitory concentration index NCCLS National Committee for Clinical Laboratory Standards the orders carnivore (e.g., dogs and cats), rodentia (e.g., mice, MIC minimum inhibitory concentration guinea pigs, and rats), and primates (e.g., humans, chimpan MOPS (3-N-Morpholinopropanesulfonic acid) Zees, and monkeys). In a particular embodiment of interest, OD optical density the Subject or patient is a human. PDA Potato Dextrose Agar Representative fungal conditions that may be treated SDA Sabouraud Dextrose Agar according to the Subject methods are those caused by the following pathogenic species: Candida spp., Such as C. albi cans, C. glabrata, C. tropicalis, C. guilliermoruli, C. haemu 25 Example 1 lonii, C. krusei, C. parapsilosis, C. lusitaniae, C. norvegensis, C. viswanathi, and C. kefir, Hyaline molds, such as Aspergil lus filmigatus, A. flavus, A. niger, A. terreus, Geotricium can Assay for Determining MIC and FICI didum, Pseudallescheria boydii, Histoplasma capsulatum The following assay was used to determine the minimum (var. capsulatum), Coccidioides immitis, Cryptococcus 30 inhibitory concentration (MIC) and fractional inhibitory con bidus, C. laurentii, and C. fitsarium, as well as Mucormycotic centration index (FICI) for combinations of antifungal agents organisms, e.g., Zygomycetes spp.; such as Rhizopus pusillus, and antibacterial agents. This assay and methods for calcu Cunninghamelle bertholletiae, Saksenaea vasiformis, Mucor lating FICI are well known in the art. See, for example, ramosissimus, Absidia corymbifera, Apophysomyces Eliopoulos, E.G. and R. Moellering, Jr. “Antimicrobial Com 35 binations' in Antibiotics in Laboratory Medicine, edited by V. elegans, Cokeromyces recurvatus, and Syncephalastrum Lorian, 4th Ed., Williams & Wilkins, Baltimore, Md., pp. FCelloSiFi. 330-396 (1996); Shalit et al., Antimicrobial Agents and Che Accordingly, the present invention provides a method of motherapy 47(4): 1416-1418 (2003); or Afeltra et al., Antimi treating a fungal infectionina Subject, the method comprising crobial Agents and Chemotherapy 46(10):3323-3326 (2002). administering to the Subject an antifungal amount, e.g., an 40 FICI values are typically evaluated using the following amount effective to treat the Subject, of an echinocandin anti criteria: fungal agent and a glycopeptide antibacterial agent as further described herein. The compositions of this invention may also be used for coating of medical instruments or implants, agricultural FICI is 0.5 Synergistic effect 45 OS & FICI & 1.O Additive effect applications, etc. as described further, for example, in U.S. 1.O & FICI & 4.O Indifferent effect Pat. No. 6,541,506. FICI> 4.O Antagonistic effect In certain embodiments, the subject being treated suffers from both a fungal infection and a bacterial infection, where In this assay, a combination of an antifungal agent and a the bacterial infection is responsive to the glycopeptide anti 50 glycopeptide antibacterial agent was considered to be more bacterial agent employed in this invention. Accordingly, this effective than the antifungal agent alone, if the combined invention also provides a method for treating a bacterial infec compounds demonstrated eithera calculated FICI of less than tion and a fungal infection in a Subject in need of treatment, or equal to about 0.5 or a decrease of the antifungal MIC by at the method comprising administering to the Subject an anti least a one-fold dilution factor. fungal amount of an echinocandin antifungal agent and an 55 antibacterial amount of a glycopeptide antibacterial agent as A. Fungal Strains further described herein. The fungal strains used in this assay are highly infectious. Representative bacterial infections or medical conditions Standard safety measures, such as use of disposable screw that may be treated include those caused by the following: cap tubes and use of safety masks, were strictly followed. All staphylococci, including methicillin-resistant staphylococci 60 work was conducted in a Biosafety Level 2 cabinet. All mate and severe staphylococcal infections, such as staphylococcal rials and equipment (e.g., pipefters and incubators) were endocarditis and staphylococcal septicemia; enterococci, decontaminated between experiments. including Vancomycin-resistant enterococci (VRE); Strepto The fungal strains used in this assay were obtained from the cocci, including -resistant pneumoniae (PRSP); AmericanType Culture Collection (ATCC), Manassas, Va. In severe streptococcal infection, Such as hospital and commu 65 the table below, the ATCC deposit number for each strain is nity acquired pneumonia (HAP and CAP); otitis media; and indicated under the column heading ATCC. Other strains the like. can be used if desired. US 7,452,861 B2 22 ence Method for Broth Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically: Approved Stan dard” (NCCLS document M7-A6): NCCLS 2002, “Refer ATCC Source/Description ence Method for Broth Dilution Antifungal Susceptibility Yeasts Strains 5 Tests of Filamentous Fungi that Grow Aerobically; Approved Standard” (NCCLS document M38-A); and NCCLS 2002 24433 Nail infection “Reference Method for Broth Dilution Antifungal Suscepti Candida parapsilosis 22019 Case of spruce, Puerto Rico 750 Patient with bronchomycosis bility Tests of Yeast; Approved Standards-2nd Edition' (NC Candida krusei 32672 Human, New Zealand CLS document M27-A2). 200918 Human tongue, Santa Rosa, 10 California B. Test Compounds and Sources Cryptococci is neoformans 56991 Human, Zaire The following semi-synthetic glycopeptide antibiotic was tested in this assay:

wherein R' and R" are as defined as follows: RI R7

Compound 1

Compound 1, also known as telavancin, was prepared as -continued described in Example 2 of U.S. Pat. No. 6,635,618 B2. Van 50 comycin was purchased from Sigma-Aldrich (St. Louis, ATCC Source/Description Mo.). Hyaline Molds Strains was purchased from U.S. Pharmacopeia (Rockville, Md.). , (formulated as Aspergilius finigatus 14110 Human sputum VFENDR) and caspofungin acetate (formulated as CANCI Aspergiiitisfia vils 64025 Human sputum, Ohio 55 DAS(R) were purchased from Peninsula Pharmacy (Burlin Fusarium moniiforme 38159 Human, California game, Calif.). Fluconazole was purchased as DIFULCANR) Geotricium candidum 62231. Ulcer in human mouth (oral formulation) and purified prior to use. Pseudaliescheria boydii 36283 Human brainabcess An initial stock of each compound was made in an appro Zygomycetes spp. Strains priate solvent, i.e., either a DMSO solution for Compound 1. Mucor circineioides 26759 Torn wounds, human, Canada 60 Vancomycin and fluconazole; or a sterile water Solution Rhizopus microsports 14050 Fatal human Rhizopus infection according to the instructions of the Supplier for Voriconazole and caspofungin. C. Dilution Ratios Procedures, protocols, Supplies and equipment used in this Using a checkerboard method, a 2-fold dilution 100x final assay follow the recommendations approved and published 65 concentration master plate was prepared using a 96-well by the National Committee for Clinical Laboratory Standards U-shape microtiter plate and an appropriate solvent. In the (NCCLS), Wayne, Pa. as described in NCCLS 2003, “Refer “checkerboard' method, a microtiter plate is divided into US 7,452,861 B2 23 24 “columns' in which each well in the column contains the mammalian cells, was used according to the NCCLS guide same amount of an antifungal agent (Compound A) being lines for yeast and filamentous fungi Susceptibility testing. diluted along the x-axis, and “rows' in which each well in the The medium was buffered with 0.165 M 3-N-morpholino row contains the same amount of a glycopeptide antibacterial propanesulfonic acid (MOPS) supplemented with 20 g/L glu agent (Compound B) being diluted on the y-axis. Also cose and pH adjusted to 7.0 with hydrogen chloride. Sab included is a row (or column) for Compound A or B alone. ouraud Dextrose Agar (SDA) slants and plates, and Potato The dilutions used in the checkerboard are exponential (by Dextrose Agar (PDA) plates were purchased from Hardy powers of two). The result is that each well in the microtiter Diagnostic (Santa Maria, Calif.). plate contains a unique concentration of the two compounds Yeast cultures were started from -80° C. frozen stock being tested. 10 streaked on SDA slants and incubated at 35°C. under aerobic A matrix 2x final concentration was performed by trans conditions for 24h. The slants were kept in the refrigerator for ferring 30 uL of 100x Compound A and Compound B into a up to 2 weeks and used regularly as a starting culture. About 1,440 LL RPMI in deep wells (one deep well per drug com 24 to 48 h before each assay was run, yeasts were streaked on bination). After mixing, 100 uL of 2x drug combinations SDA plates for isolated colonies. To prepare the inoculum, were distributed into 96-well microtiter plates. Compound A 15 from one to four colonies were resuspended in 5 mL of saline, was diluted from Column 1 starting at 1,600 g/mL to Col and vortexed for 15 sec. umn 11 (1.6 ug/mL). Wells in Column 1 contained a final Molds started from -80° C. frozen stocks were spotted in concentration (after inoculum was added) of 16 ug/mL of the center of the PDA plates. The plates were incubated at 35° Compound A: Wells in Column 2 contained a final concen C. for 7 days to induce conidiospores and sporangiospores. tration of 8 ug/mL of Compound A; wells in Column 3 con Fast growing molds (i.e., Fusarium spp. and Rhizopus spp.) tained a final concentration of 4 ug/mL of Compound A. etc. were incubated at 35° C. for 48 to 72 h, then kept at 25-28°C. Compound A was not added to Column 12, so Column 12 for up to 7 days. To prepare the inoculum, the mold spores contained only Compound B. were resuspended in Saline (avoiding aerosol formation), then Compound B was diluted from row A starting at 6,400 vortexed for 15 sec, and the hypheal particles were allowed to ug/mL down to row G (100 ug/mL). Wells in Row A con 25 Settle for 5 to 10 min. tained a final concentration of 64 ug/mL of Compound B; The initial optical density (OD) at 530 nm of the vortexed Row B contained a final concentration of 32 g/mL of Com cells Suspended in Saline was less than 0.5 as measured using pound B; Row C contained a final concentration of 16 ug/mL a SmartSpec 3000 spectrophotometer (BioRAD. Hercules, of Compound B; etc. Compound B was not added to Row H. Calif.). For most yeast and mold cultures, the optical density so Row H only contained Compound A. 30 (OD) of the suspension was adjusted to 0.11 in saline to Shown below is an example of a 96-well microtiter plate provide -0.4x10 CFU/mL. However, for Fusarium monili format used with combined Compound A and Compound B. forme and Pseudalescheria boydii the OD of the suspension Concentrations noted on the rows and columns are the final was adjusted to OD=0.17 to provide -0.4x10 CFU/mL. ones after inoculum were mixed with the combined com Then the culture was diluted 1:1,000 for yeasts and 1:50 for pounds. molds in RPMI media (GIBCO-BRL) to get a 2x final inocu

Compound B Compound A (ugmL final) Compound

(ig/mL 16 8 4 2 1 O.S. O.25 O.125 OO63 O.O31 O. O15 O B final) 1 2 3 4 S 6 7 8 9 10 11 12 (ig/mL final)

64 A. A. 64 32 B B 32 16 C C 16 8 D D 8 4 E E 4 2 F F 2 1 G G 1 O H H O

1 2 3 4 S 6 7 8 9 10 11 12 16 8 4 2 1 O.S. O.25 O.125 OO63 O.O31 O. O15 O

In most cases, MIC of the glycopeptide antibacterial com 55 lum. A final inoculum of 0.5x10 to 2.5x10 CFU/mL pound alone was >64 Lug/mL. In order to get an accurate (yeasts) and 0.4x10 to 5x10 CFU/mL (molds) was used to measurement, a standard MIC assay using NCCLS protocols ensure greater reproducibility of test results. was performed with an extended concentration range of from Using an 8-channel multipipetter, 100 uL of the 2x inocu 256 g/mL to 0.25 ug/mL. The MIC of the glycopeptide lum was added to 100 uL of 2x drug dilution starting from the antibacterial compound determined from this experiment was 60 lowest dilution to the highest. Microtiter plates were incu used in FIC calculations. If the MIC of the antibiotic com bated at 35° C. under aerobic conditions for 48 h before pound was >256 g/mL, FIC of the compound was calculated reading the results. Plates were read after about 24h (Rhizo using 256 ug/mL as the closest value to the true MIC. pus spp.) or 72 h (Cryptococcus neoformans). D. Media and Inoculum Preparation 65 Additionally, for validation purposes (i.e., to confirm the RPMI-1640 without sodium bicarbonate media (GIBCO accuracy of the pipetted inoculum amount and the viability of BRL, Carlsbad, Calif.), an enriched media formulated for cells) 100 uL of the inoculum was plated on a separate SDA US 7,452,861 B2 25 26 plate. If, after about 46 to about 48 hours, the inoculum size F. Results and Discussion calculated from the colony count on the validation plate was The results of the assays are shown in Tables 1, 2 and 3. outside the expected range of 0.5x10 to 2.5x10 CFU/mL (yeasts) and 0.4x10" to 5x10 CFU/mL (molds), the entire TABLE 1 assay test was redone. 5 FICI for Combinations of Glycopeptide Antibacterial After about 46 to about 48 hours, the growth of the fungus Agents and Caspofungin in the 96-well microtiter plates was evaluated and the mini mum inhibitory concentration (MIC) and fractional inhibi FICI tory concentration (FIC) were calculated. 10 Fungal Strains Compound 1 Vancomycin Each column and row of the microtiter plates was visually C. albicans ATCC 24433 0.27 2.00 assessed for cell growth, which manifested as clouding or C. parapsilosis ATCC 22019 O.38 2.00 C. tropicalis ATCC 750 O.26 2.00 turbidity of the media. RPMI media was clear and transparent C. krusei ATCC 32672 O.31 2.00 at inoculation. When no turbidity was observed, the growth of 15 C. glabrata ATCC 200918 O.28 2.00 the inoculum cells was inhibited, and the well remained clear. The minimum inhibitory concentration (MIC) of a com pound, i.e., the minimum inhibitory concentration of com TABLE 2 pound A (MIC), is the concentration of compound A at which no growth is observed. 2O FICI for Combinations of Compound 1 and Caspofungin Fungal Strains FICI E. Measurement of Synergy Effects C. albicans ATCC 24433 0.27 To measure the in vitro interactions of test compounds, the C. parapsilosis ATCC 22019 O.38 Fractional Inhibitory Concentration was calculated using the C. tropicalis ATCC 750 O.26 25 C. krusei ATCC 32672 O.31 concentration that reduced the antifungal compound MIC by C. glabrata ATCC 200918 O.28 at least a 2-fold dilution factor (i.e., “concentration of com C. neoformans ATCC 56991 0.75 pound in synergistic well’). The Fractional Inhibitory Con A. fumigatus ATCC 14110 O.28 A. terretts ATCC 46941 O.31 centration for compound A, FIC(A) is equal to the concen A. flavus ATCC 64025 O16 tration of compound A in synergistic well divided by MIC(A). 30 F moniliforme ATCC 38159 2 Similarly, for compound B, the FIC(B) is equal to the con S. prolificans ATCC 200543 1.25 P. boydii ATCC 38283 O.31 centration of compound B in synergistic well divided by G. candidum ATCC 62231 O.31 MIC(B). The Fractional Inhibitory Concentration Index M. Circinelioides ATCC 26759 2 R. miscosporus ATCC 14050 2 (FICI) is equal to the sum of FIC(A)+FIC(B). 35

concentration (A) in synergistic well TABLE 3 FIC(A) = MIC(A) concentration (B) in synergistic well FICI for Combinations of Compound I and Antifungal Agents FIC(B) = 40 MIC(B) FICI FICI = FIC(A) + FIC(B) Fungal Strain Fluconazole Miconazole Voriconazole C. albicans ATCC 24433 2.00 2.00 Not For each combination of test compounds, the assay was 45 Applicable C. parapsilosis ATCC 22019 2.00 2.00 Not repeated at least twice to show reproducibility. Because MICs Applicable have an inherent 50% error associated with the assay, no C. tropicalis ATCC 750 2.00 2.00 Not average or statistical analysis was performed. FICs however Applicable C. krusei ATCC 32672 2.00 Not 1.13 are not affected by the MIC variability. Determined The calculated value for the FICI of the combined test 50 C. glabrata ATCC 200918 2.00 Not 1.13 compounds was compared to the following standards in cer Determined tain embodiments: The data in Tables 1, 2 and 3 demonstrate that combina 55 tions of an echinocandin antifungal agent, such as caspofun FICIs O.5 synergistic effect gin, and a glycopeptide antibacterial agent having a substitu FICI O.S nonsynergistic effect ent comprising at least about 8 carbon atoms, such as telavancin, typically have a synergistic or additive effect The interactions of the combined compounds can be against various strains of fungi. For example, the combination expressed as a graph in which antifungal MIC (ug/mL) is of Compound 1 and caspofungin was synergistic against all plotted on the Y-axis as a function of antibacterial concentra yeast strains tested, except C. neoformans against which tion (ug/mL) which is plotted on X-axis. If desired, the Syn caspofungin has no activity. ergistic interaction of the two combined compounds can alter In contrast, the combination of Vancomycin and caspofun natively be calculated or validated with other assays, such as 65 gin was not synergistic or additive. Moreover, azole antifun a time-kill Synergy assay as discussed in Eliopoulos, E. G. gal agents did not show a synergistic or additive effect when and R. Moellering, Jr. combined with the glycopeptide antibacterial agents. US 7,452,861 B2 27 28 These results clearly demonstrate that the present invention 4. A method for treating a fungal infection in a subject, the provides significant advantages for administering an echi method comprising: nocandin antifungal agent to a subject in need thereof. More administering to the Subject an antifungal amount of an specifically, by administering Such an echinocandin antifun echinocandin antifungal agent selected from caspofun gal agent in combination with a specified glycopeptide anti gin or a pharmaceutically acceptable salt thereof, and a bacterial agent, the efficacy of the echinocandin antifungal glycopeptide antibacterial agent selected from telavan agent is significantly increased thereby allowing for reduced cin or a pharmaceutically acceptable salt thereof. dosages (e.g., to reduce or eliminate toxicity), quicker treat wherein the fungal infection is caused by Candida albi ment protocols, etc. cans, Candida parapsilosis, Candida tropicalis, Can While the present invention has been described with refer 10 dida krusei, Candida glabrata, Aspergillus fumigatus, ence to specific aspects or embodiments thereof, it will be Aspergillus terreus, Aspergillus flavus, Pseudallesche understood by those of ordinary skill in the art that various ria boydii, Geotricium candidum, or a combination changes can be made or equivalents can be substituted with thereof. out departing from the true spirit and scope of the invention. 5. The method according to claim 4, wherein the echi Additionally, to the extent permitted by applicable patent 15 nocandin antifungal agent and the glycopeptide antibacterial statues and regulations, all publications, patents and patent agent are administered sequentially. applications cited herein are hereby incorporated by refer 6. The method according to claim 4, wherein the echi ence in their entirety to the same extent as if each document nocandin antifungal agent and the glycopeptide antibacterial had been individually incorporated by reference herein. agent are administered simultaneously. What is claimed is: 7. A method for increasing the efficacy of an echinocandin 1. A method for administering an echinocandin antifungal antifungal agent, the method comprising administering the agent to a subject having a fungal infection, the method com echinocandinantifungal agent selected from caspofungin or a prising: pharmaceutically acceptable salt thereof, to a subject in com administering to the Subject an echinocandin antifungal bination with a glycopeptide antibacterial agent selected from agent selected from caspofungin or a pharmaceutically 25 acceptable salt thereof, and a glycopeptide antibacterial telavancin or a pharmaceutically acceptable salt thereof; agent selected from telavancin or a pharmaceutically wherein the Subject has a fungal infection caused by Can acceptable salt thereof; dida albicans, Candida parapsilosis, Candida tropica wherein the fungal infection is caused by Candida albi lis, Candida krusei, Candida glabrata, Aspergillus filmi cans, Candida parapsilosis, Candida tropicalis, Can 30 gatus, Aspergillus terreus, Aspergillus flavus, dida krusei, Candida glabrata, Aspergillus fumigatus, Pseudallescheria boydii, Geotricium candidum, or a Aspergillus terreus, Aspergillus flavus, Pseudallesche combination thereof. ria boydii, Geotricium candidum, or a combination 8. The method according to claim 7, wherein the echi thereof. nocandin antifungal agent and the glycopeptide antibacterial 2. The method according to claim 1, wherein the echi 35 agent are administered sequentially. nocandin antifungal agent and the glycopeptide antibacterial 9. The method according to claim 7, wherein the echi agent are administered sequentially. nocandin antifungal agent and the glycopeptide antibacterial 3. The method according to claim 1, wherein the echi agent are administered simultaneously. nocandin antifungal agent and the glycopeptide antibacterial agent are administered simultaneously. k k k k k